ABOUT: Particularly when just starting residency, dictating efficient and concise operative notes can be somewhat daunting.  We have compiled a list of common dictation examples to get you started.  Please also refer to our Surgical Video Atlas, Podcast, and 3D Temporal Bone Atlas for related content. Remember, operative notes carry significant medicolegal implications and it is your responsibility to document accurate and clear notes that reflect the specific details of your procedure. These are only examples and all dictations must be adapted to the particular encounter.

In addition to the describing the surgical narrative, most operative notes include these additional entries, but this may vary according to specific institutional preferences:

PREOPERATIVE DIAGNOSIS: ___
POSTOPERATIVE DIAGNOSIS: ___
PROCEDURE: ___
SURGEON: ___
ASSISTANT: ___
ANESTHESIA: ___ (e.g. GETA, general mask, local)
ESTIMATED BLOOD LOSS: ___
SPECIMENS: ___
INDICATION: ___
KEY FINDINGS: ___
COMPLICATIONS: ___

PEDIATRIC OTOLARYNGOLOGY TABLE OF CONTENTS

1. PE Tubes

2. Adenotonsillectomy

3. Tonsillectomy with Superior Segment Adenoidectomy

4. Frenulectomy

5. Microdirect Laryngoscopy and Rigid Bronchoscopy (MLB)

6. LASER Supraglottoplasty with Microdirect Laryngoscopy and Rigid Bronchoscopy

7. Cold Supraglottoplasty with Microdirect Laryngoscopy and Rigid Bronchoscopy

8. Sistrunk Procedure for Thyroglossal Duct Cyst Excision

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general mask anesthesia was successfully obtained by the anesthesia service, the patient was positioned for PE tube placement and operating microscope was brought into the field. An ear speculum was inserted into the ___ ear canal and obstructing cerumen was gently removed to improve tympanic membrane visualization. A myringotomy was fashioned in the ___ quadrant, and ___ fluid was found in the middle ear space. A ___ tube was placed without difficulty, ___ drops were instilled and a cotton ball was placed. Attention was then turned to the opposite side and an identical procedure was performed. An ear speculum was inserted into the ___ ear canal and obstructing cerumen was gently removed to improve tympanic membrane visualization. A myringotomy was fashioned in the ___ quadrant, and ___ fluid was found in the middle ear space. A ___ tube was placed without difficulty, ___ drops were instilled and a cotton ball was placed. This marked the end of the procedure.  The patient was awakened, and transferred to the PACU in stable condition.  All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure. 

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. General endotracheal anesthesia was successfully induced by the anesthesia service.  The patient was placed in the supine position and draped in the usual sterile fashion. The McIvor mouth gag was inserted into the mouth and opened exposing symmetrically enlarged ___ tonsils.  Care was taken to ensure that the lips were not pinched by the mouth gag. The uvula was midline and not bifid. The soft palate was intact with no evidence of submucousal clefting.  A single moistened tonsil sponge was placed over the laryngeal introitus. The right tonsil was grasped with an Allis clamp, retracted medially, and dissected free of the tonsillar fossa in a pericapsular plane.  Electrocautery, set at ___ watts, was used just after pausing to verify that the inspired O2 was less than ___%. Minimal bleeding was found and meticulously controlled using electrocautery.  A similar procedure was performed on the left.  Minimal bleeding was found on this side and again meticulously controlled using electrocautery.

Attention was then turned toward the adenoid pad. Two red rubber catheters were inserted through the nose on both sides, advanced through to the oropharynx, and pulled out the mouth effectively suspending the soft palate.  A mirror was used to directly visualize a ___ adenoid pad.  Using suction cautery on ___ watt spray, the adenoid tissue was ablated.  Care was taken to identify and preserve the torus bilaterally as well as the vomer and the soft palate.  Minimal bleeding was noted and easily controlled with suction cautery.  The red rubber catheters were then removed.  The patient was desuspended for 2 minutes and resuspended. No bleeding was noted.  The tonsil sponge followed by the McIvor mouth gag was removed.  The stomach was suctioned.  At this point the procedure was terminated.  The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. General endotracheal anesthesia was successfully induced by the anesthesia service.  The patient was placed in the supine position with a shoulder roll and draped in the usual fashion. The ___ mouth gag was used to expose the oropharynx.  The junction of the bony and soft palate was visualized and palpated.  Palate findings included ___.   On FiO2 pause was undertaken and was confirmed to be below ___%. The right tonsil was secured with an ___ clamp.  An incision was made over the anterior tonsillar pillar, starting from the inferior direction and carried to the superior pole.  The capsule was identified, and using ___ dissection technique, the tonsil was removed. Bleeding spots were coagulated.  The left tonsil was removed in a similar fashion. A catheter was passed through the nose for palatal elevation.  The nasopharynx was inspected with a mirror showing an enlarged adenoid pad, which was taken down only to the level of Passavant's ridge for superior segment adenoidectomy. Careful attention was paid not to violate the vomer, torus, the eustachian tube orifice, or soft palate. The catheter was removed.  The tonsillar fossae were reinspected.  Very minor bleeding spots were coagulated.  Next ___ cc of ___ % ___ was injected into the tonsillar fossa bilaterally. The contents of the esophagus and stomach were emptied with an orogastric tube. At this point the procedure was terminated.  The patient was awakened, extubated, and transferred to the PACU in stable condition.  All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure. 

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. General endotracheal anesthesia was successfully induced by the anesthesia service.  The patient was placed in the supine position and draped in the usual fashion. The ___ was used to elevate the tongue, exposing the lingual frenulum.  The frenulum was injected with ___% lidocaine with ___ epinephrine.  A straight clamp was used to clamp the frenulum just on the ventral surface of the tongue. Scissors were used to divide the tight frenulum posteriorly until fully released.  The diamond shaped mucosal defect was closed with interrupted ___-0 ___ suture.  This released the tip of the tongue significantly. At this point the procedure was terminated.  The patient was awakened, extubated, and transferred to the PACU in stable condition. There was minimal blood loss.  No complications.  All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general mask anesthesia was successfully obtained by the anesthesia service, the patient was positioned supine for airway examination. A ___ was used to protect the upper alveolus. Using the ___ intubating ___ laryngoscope, the supraglottic structures were visualized, and approximately ___ cc of ___% lidocaine was used to topically anesthetize the bilateral vocal folds. After an adequate period of waiting, the patient’s larynx was re-exposed.  A _-0 endotracheal tube was placed via the left naris for blow-by anesthesia.  The 0-degree 4-mm (vs 2.7mm) rigid endoscope was used for microlaryngoscopy.  (Include pertinent findings) The supraglottic structures including the epiglottis, area epiglottic folds, arytenoids, and vocal folds appeared normal.  Spread of the arytenoids bilaterally demonstrated intact mucosa with no evidence of laryngeal cleft.  The vocal folds were unable to be fully assessed for mobility due to the plane of anesthesia.  The scope was removed and the patient was de-suspended.  This terminated the microlaryngoscopy portion of the procedure. Following resuspension, rigid bronchoscopy was undertaken. The ___-degree ___-mm rigid endoscope was introduced into the subglottis, trachea, and proximal bronchi.  (Include pertinent findings). Photographic documentation was obtained throughout the procedure. This marked the end of the procedure.  The patient was awakened, and transferred to the PACU in stable condition.  All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general mask anesthesia was successfully obtained by the anesthesia service, the table was turned and the patient was positioned supine for airway examination. General anesthesia was titrated to permit spontaneous patient ventilation. A ___ was used to protect the upper alveolus.  Using the ___intubating ___laryngoscope, the supraglottic structures were visualized, and approximately ___cc of _% lidocaine was used to topically anesthetize the bilateral vocal folds.  After an adequate period of waiting for anesthetic effect, the patient’s larynx was again exposed using a ___ laryngoscope.  The airway examination was then performed using a ___-mm rigid telescope, revealing the aforementioned findings of the redundant, narrow aryepiglottic folds and arytenoid mucosa (report findings here).  The telescope was then passed through the true vocal cords.  The subglottis was found to be ___, and the trachea showed ___ to the carina and mainstem bronchi, which appeared normal. The patient was then suspended from the table and the operating microscope was brought into the field.

The CO2 laser, which had been tested prior to the operation's start, was focused on the left aryepiglottic fold.  Using ___ watts at ___ joules, the laser was used to divide the aryepiglottic fold laterally, with a diffuse spray of the laser to reduce the redundancy of the arytenoid mucosa.  A moistened pledget was used to remove the excess char, and this was repeated on the right-hand side.  At the conclusion of the procedure, the supraglottis was widely patent with a good view of the glottis with no significant laryngomalacia persisting. At this point the patient was intubated with a ___-0 uncuffed endotracheal tube and transported to the intensive care unit in stable condition. All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general mask anesthesia was successfully obtained by the anesthesia service, the table was turned and the patient was positioned supine for airway examination. General anesthesia was titrated to permit spontaneous patient ventilation. A ___ was used to protect the upper alveolus.  Using the ___intubating ___laryngoscope, the supraglottic structures were visualized, and approximately ___cc of _% lidocaine was used to topically anesthetize the bilateral vocal folds.  After an adequate period of waiting for anesthetic effect, the patient’s larynx was again exposed using a ___ laryngoscope.  The airway examination was then performed using a ___-mm rigid telescope, revealing the aforementioned findings of the redundant, narrow aryepiglottic folds and arytenoid mucosa (report findings here).  The telescope was then passed through the true vocal cords.  The subglottis was found to be ___, and the trachea showed ___ to the carina and mainstem bronchi, which appeared normal. The patient was then suspended from the table and the operating microscope was brought into the field.

The ___ suspension laryngoscope was then introduced and the larynx was exposed.  The operating microscope was brought into the field.  Supraarytenoid tissue on the right side was grasped.  An incision was made along the aryepiglottic fold using ___.  The tissue was then reflected forward, and the supraarytenoid tissue above the arytenoid cartilage was amputated with careful attention not to violate the interarytenoid mucosa.  Similar procedure was performed on the left side.  At the conclusion of the procedure, the supraglottis was widely patent with a good view of the glottis with no significant laryngomalacia persisting. At this point the patient was intubated with a ___-0 uncuffed endotracheal tube and transported to the intensive care unit in stable condition. All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.

DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the table was turned. A ___ incision was marked and injected with ___ and a shoulder roll was placed. The patient was prepped and draped in the usual fashion for thyroglossal duct cyst excision.

A ___ cm midline incision was made and subplatysmal flaps were elevated from just superior to the hyoid to the cricoid cartilage. We then palpated and identified the cyst ___.  The strap musculature was then elevated bilaterally.  The inferior aspect of the cyst was evaluated and there ___ a tract that continued to the thyroid gland. This was divided at the gland.  The cyst was then elevated superiorly to the hyoid. The straps were cut just lateral to the cyst at the hyoid.  Using monopolar cautery, a cuff of muscle was divided superior to the hyoid.  We then bluntly dissected around the hyoid just lateral to the cyst on either side and divided the hyoid bone using a ___. There was ___ pharyngotomy identified. We then placed a ___ transorally and keeping the fields separate, palpated the ___ through the neck at the foramen cecum at the base of the tongue.  The cuff of muscle was then transected and suture ligated to prevent any potential fistula.  The specimen was sent to pathology and was consistent with a thyroglossal duct cyst.

The wound was irrigated and hemostasis was ensured. A ___ drain was placed.  The incision was closed in layered fashion with ___. This marked the end of the procedure.  The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed.  Standard operating room protocol and universal precautions were utilized throughout the procedure.